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ORIGINAL ARTICLE
Year : 2022  |  Volume : 40  |  Issue : 1  |  Page : 62-66
 

Effect of silver diamine fluoride, potassium iodide, and glutathione on micro-shear bond strength of glass ionomer cement to caries affected dentine


Department of Conservative Dentistry and Endodontics, K.L.E Society's Institute of Dental Sciences, Bengaluru, Karnataka, India

Date of Submission11-Mar-2021
Date of Decision28-Jan-2022
Date of Acceptance05-Feb-2022
Date of Web Publication13-Apr-2022

Correspondence Address:
Dr. Deepthy Priya
Department of Conservative Dentistry and Endodontics, K.L.E Society's Institute of Dental Sciences, #20, Yeshwanthpur Suburb, II Stage, Tumkur Road, Bengaluru - 560 022, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jisppd.jisppd_96_21

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   Abstract 


Background: Silver diamine fluoride (SDF, 38%) is an efficient topical fluoride used to arrest dental caries though it causes black staining of both teeth and restoration. The application of potassium iodide (KI) after SDF reduces the stain, but the color change is only temporary. An alternative method suggested is by mixing glutathione (GSH) with SDF, which preserves the silver ions of SDF within the solution. Hence, the purpose of this in vitro study was to evaluate the microshear bond strength (μSBS) of glass ionomer cement (GIC) to caries affected dentin (CAD) pretreated with SDF/KI/GSH. Materials and Methods: Thirty dentine slices of 2 mm thickness from human permanent upper premolars were demineralized using pH cycling method to mimic CAD. They were allocated to three groups of 10 each and treated with SDF, SDF-KI (SDF followed by KI), SDF + GSH (SDF mixed with GSH), respectively. Specimens were bonded with GICs. The μSBS was assessed using a universal testing machine and the data obtained were analyzed using one-way ANOVA and Tukey's post hoc test. Results: The μSBS (mean ± standard deviation) values for groups SDF, SDF-KI, and SDF + GSH were 4.81 ± 2.026, 5.78 ± 1.809, 8.18 ± 2.828 megapascal respectively. Group 3 showed significantly better bond strength compared to groups 1 and 2. In group 2, the addition of KI showed better bond strength when compared to group 1, but the difference was not statistically significant. Conclusion: Pretreatment of teeth with GSH along with SDF application showed significantly better bond strength of GIC to CAD compared to SDF and SDF-KI.


Keywords: Caries affected dentin, glass ionomer cement, glutathione, microshear bond strength, potassium iodide, silver diamine fluoride


How to cite this article:
Priya D, Karale R, Prashanth B R, Raj A, Vathsala Heggade K N. Effect of silver diamine fluoride, potassium iodide, and glutathione on micro-shear bond strength of glass ionomer cement to caries affected dentine. J Indian Soc Pedod Prev Dent 2022;40:62-6

How to cite this URL:
Priya D, Karale R, Prashanth B R, Raj A, Vathsala Heggade K N. Effect of silver diamine fluoride, potassium iodide, and glutathione on micro-shear bond strength of glass ionomer cement to caries affected dentine. J Indian Soc Pedod Prev Dent [serial online] 2022 [cited 2022 May 23];40:62-6. Available from: https://www.jisppd.com/text.asp?2022/40/1/62/343022





   Introduction Top


Silver diamine fluoride (SDF, 44,800 ppm fluoride) is a solution containing ionic silver, fluoride and ammonia, that arrests the progress of carious lesion and prevents the development of future caries.[1] It inhibits dentine demineralization and prevents degradation of collagen[2] and increase the micro-hardness of tooth structure.[3]

SDF allows a more conservative tooth preparation because it effectively remineralizes remaining decay.[4] Silver ions in SDF are known to have intense antimicrobial effect as it inhibits the cariogenic biofilm formation by interfering with the bacterial synthesis of cellular polysaccharides.[4],[5] When compared to fluoride varnish, SDF is effective in the prevention of caries.[6] However, SDF forms black stains on the tooth structure. Its clinical use is limited due to esthetic concerns.[7]

SDF stain can be masked either by restoring the cavity with glass ionomer cement (GIC)/Composites[2] or by application of supersaturated solution of potassium iodide (KI) immediately after SDF followed by GIC restoration. KI is widely used as a nutritional supplement.[4] However, the application of SDF and KI together has shown to reduce the number of free silver ions, and over long term, it may decrease the merits of SDF dramatically.[8] An alternative method has been suggested to decrease the staining and to preserve the silver within the solution and on the substrate surface is by mixing glutathione (20% GSH) with SDF. GSH is an intracellular nonprotein thiol (NPSH) that acts as a reducing agent (antioxidant) in mammalian cells.[9]

Various studies have shown the compatibility of SDF with GIC restorations, but little is known about the effect of additives used to mask the discoloration, on the bond strength of GIC to caries affected dentine (CAD) pre-treated with SDF, KI, and GSH. Therefore, the aim of this in vitro study was to evaluate the microshear bond strength (μSBS) of GIC to artificial CAD pretreated with SDF, KI, and GSH.

The null hypothesis tested was that the application of these solutions would not affect adhesion to demineralized dentine.


   Materials and Methods Top


Thirty noncarious human permanent premolars extracted for orthodontic and periodontal reasons were collected and stored in 0.1% thymol solution until use. 30 dentine slices of 2 mm thickness were prepared using a low-speed diamond saw under water coolant. Specimens were then embedded on acrylic resin. The surfaces of the dentine slices were polished with microfine 2000-grit sandpaper under running water. Artificial dentine carious lesions were induced by a pH-cycling procedure, by immersing in a demineralizing solution (pH 4.4, 50 mM acetate, 2.2 mM KH2PO4, 2.2 mM CaCl2) for 7 days.[10]

The samples were then divided randomly into three groups depending on pre-treatment with various solutions (n = 10 per group): Group 1, the control group (38% SDF), Group 2 (SDF-KI), Group 3 (SDF + 20%GSH). The randomization was achieved by allocation concealment and implementation.

For group I (SDF), the demineralized surfaces were treated with 38% SDF (FAgamin, Tedequim) solution and agitated for 1 min using a microbrush and air-dried.

For group II (SDF-KI), i.e., KI followed by SDF, a saturated solution of KI was prepared by diluting KI (SDFCL, SD fine-chem limited) in distilled water. The demineralized surfaces were treated with 38% SDF solution, with immediate application of the prepared solution until creamy white precipitates turned clear, then washed with copious distilled water for 30 s and air dried.

For group III (SDF + GSH), 20% GSH was prepared by mixing 200 mg of GSH (Maxiliv GSH injection 600 mg-Zuventus healthcare) in 1 ml sterile water until it is completely dissolved. The prepared solution (20% GSH) was mixed with equal quantity of SDF until the solution became clear without any precipitates. The demineralized surfaces were treated with the solution (20% GSH + SDF) using a microbrush and rinsed with copious distilled water for 30 s and air-dried.

All the demineralized dentine samples were bonded with GICs by placing a silicone mold with 2 mm height and 0.8 mm diameter. After bonding, all samples were stored in 100% humidity at 37°C for 24 h to allow the complete setting of GICs.

Thermocycling of 1000 cycles in 55 ± 5°C distilled water was done with 1 minute dwell time and a 14 s interval between baths. After thermocycling, all samples were subjected to μSBS testing. The samples were fixed on the mechanical jaw of universal testing machine (Mecmesin, Multitest 10i) with a steel knife-edge loading head, which was positioned such that force was applied perpendicular to the GIC restoration at a distance of 1 mm from the dentine surface to the loading head. The load was applied at a strain rate of 1 mm/min until bond failure.

Statistical analysis

The data obtained were analyzed with SPSS version 19.0 software using one-way ANOVA and Tukey's post hoc tests. A P value lower than 5% was considered statistically significant.


   Results: Mean Micro Shear Bond Strength Analysis (in Mega Pascal) Top


The mean micro shear bond strengths of GICs to dentine are shown in [Figure 1].
Figure 1: Mean micro shear bond strengths of glass ionomer cements to dentine

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Results showed that P values were statistically significant for Group 3 when compared to Group 1 (P = 0.007) and Group 2 (P = 0.062). Group 2 showed better bond strength when compared to Group 1 but the difference was not statistically significant. Group 2 and Group 3 showed better bond strength when compared to Group 1 [Table 1] and [Table 2].
Table 1: Multiple comparisons

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Table 2: Descriptive statistics and ANOVA test

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   Discussion Top


The staining effect of SDF limits its usage in adult dentition due to esthetic concerns even though its ability to arrest dental caries is proven. GSH is a ubiquitous antioxidant master[11] and also a widely used skin whitening agent.[12] The effectiveness of GSH in reducing stain and its associated properties are still an area to be studied. Furthermore, it is critical to evaluate the effect of GSH on bond strength of GIC to make the usage more common in dentistry.

In the present study, the bond strength of GIC to CAD pretreated with SDF/KI/GSH was investigated. The study was conducted in a controlled laboratory condition in which dentine was artificially demineralized to mimic CAD using pH-cycling. CAD is partially demineralized, which reserves enough collagen fibers to be remineralized with relatively low bacterial count.[2] Hence, based on the philosophy of minimally invasive dentistry, CAD should be preserved in clinical treatment.[2] Adhesion to CAD is an issue as bond strength to this substrate is lower than sound dentine. The lower bond strengths have been mainly attributed to the obliteration of dentine tubules by acid-resistant mineral crystals, a thicker zone of exposed collagen after the application of the adhesive system, and the lower hardness of the CAD.[10]

Cavitated carious lesions can be arrested by applying SDF liquid on the lesion without removing any infected soft dentin.[13] The black discoloration was more commonly found in the CAD, due to the reaction between the unreacted silver ions and the partially denatured collagen. Its production was accelerated when exposed to light and high temperatures. Previous studies stated that SDF does not adversely affect the bond strength between GIC and tooth surface.[14],[15]

SDF application protocol followed in the present study was as per Knight et al. (2006) who recommended to wash away the precipitate layer formed after SDF application.[16] The application of saturated solution of KI followed by SDF resulted in a creamy white precipitate of silver iodide (AgI), which decreases the availability of silver ions that stain the dentin black, resulted in an improved color.[9],[17] This improvement is only temporary as the darkening of tooth surfaces eventually occurred.[4] As per Nguyen et al., adequate washing of SDF/KI precipitates, before the application of GIC, improves the bond strength of GIC to dentin.[4] In the present study, KI showed better bond strength though not statistically significant compared to SDF alone which is in accordance with the previous studies done by Knight et al. and Zhao et al. According to Zhao et al., the immediate application of KI solution after SDF does not affect the adhesion of GICs to artificial CAD. Moreover, KI treatment can reduce discoloration of demineralized dentine caused by SDF.[2]

GSH has been previously used as a biomimetic coating on silver particles to enhance interactions with complex bio-systems and increase its water solubility.[18],[19] Similarly, it forms a coat around silver particles, decreases the aggregation of silver particles and controls the rate of silver ion release, and decreases the rate of color changes of SDF-coated tooth surface over time.[19] In the present study, Group 3 (GSH) showed significantly better bond strength compared to Group 2 (SDF-KI) and Group 1 (SDF). GSH is an antioxidant which has the property of collagen cross-linking and stabilization which might have increased the bond strength of Group 3 (SDF + GSH).[20]

In the present study, the null hypothesis was rejected as group 3 (SDF+GSH) showed significantly better bond strength compared to other groups.

Sayed et al.[9] stated the effectiveness of GSH in minimizing color changes post SDF application. Furthermore, the color improvement was more evident on enamel than dentin. This is in accordance with the present study, we observed that the color improvement was only temporary as thermocycling of the samples resulted in recurrence of discoloration of dentin, which could be due to lesser formation of metallic silver on enamel than dentin and 20% GSH was sufficient for enamel to minimize color changes, but for dentin, it seems necessary to use an increased concentration of GSH to more effectively reduce color changes.


   Conclusion Top


Within the limitations of the study, it can be concluded that pre-treatment of teeth with GSH along with SDF application showed significantly better bond strength of GIC to CAD compared to SDF alone and SDF followed by KI.

Uniqueness and drawback

The application of GSH in medical filed is very common, though the possible benefits in dentistry are an area of interest for many clinicians. This study utilized the efficacy of GSH to mask the SDF stain, which addresses the esthetic concern with SDF.

In the present study, the quality of precipitate formed on the demineralized dentine samples and its effect on bond strength is not assessed, which requires further investigation.

Clinical significance

The addition of KI and GSH will help to mask the discoloration caused due to SDF without affecting the bond strength of GIC.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Burgess JO, Vaghela PM. Silver diamine fluoride: A successful anticarious solution with limits. Adv Dent Res 2018;29:131-4.  Back to cited text no. 1
    
2.
Zhao IS, Chu S, Yu OY, Mei ML, Chu CH, Lo EC. Effect of silver diamine fluoride and potassium iodide on shear bond strength of glass ionomer cements to caries-affected dentine. Int Dent J 2019;69:341-7.  Back to cited text no. 2
    
3.
Savas S, Kucukyılmaz E, Celik EU, Ates M. Effects of different antibacterial agents on enamel in a biofilm caries model. J Oral Sci 2015;57:367-72.  Back to cited text no. 3
    
4.
Nguyen V, Neill C, Felsenfeld J, Primus C. Potassium iodide. The solution to silver diamine fluoride discoloration? Adv Dent Oral Health 2017;5:555655.  Back to cited text no. 4
    
5.
Mohammadi N, Farahmand Far MH. Effect of fluoridated varnish and silver diamine fluoride on enamel demineralization resistance in primary dentition. J Indian Soc Pedod Prev Dent 2018;36:257-61.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Gao SS, Zhang S, Mei ML, Lo EC, Chu CH. Caries remineralisation and arresting effect in children by professionally applied fluoride treatment – A systematic review. BMC Oral Health 2016;16:12.  Back to cited text no. 6
    
7.
Mei ML, Ito L, Cao Y, Li QL, Lo EC, Chu CH. Inhibitory effect of silver diamine fluoride on dentine demineralisation and collagen degradation. J Dent 2013;41:809-17.  Back to cited text no. 7
    
8.
Knight GM, McIntyre JM, Craig GG, Mulyani, Zilm PS, Gully NJ. Inability to form a biofilm of Streptococcus mutans on silver fluoride- and potassium iodide-treated demineralized dentin. Quintessence Int 2009;40:155-61.  Back to cited text no. 8
    
9.
Sayed M, Matsui N, Hiraishi N, Nikaido T, Burrow MF, Tagami J. Effect of glutathione bio-molecule on tooth discoloration associated with silver diammine fluoride. Int J Mol Sci 2018;19:1322.  Back to cited text no. 9
    
10.
Marquezan M, Corrêa FN, Sanabe ME, Rodrigues Filho LE, Hebling J, Guedes-Pinto AC, et al. Artificial methods of dentine caries induction: A hardness and morphological comparative study. Arch Oral Biol 2009;54:1111-7.  Back to cited text no. 10
    
11.
Bains VK, Bains R. The antioxidant master glutathione and periodontal health. Dent Res J (Isfahan) 2015;12:389-405.  Back to cited text no. 11
    
12.
Sonthalia S, Daulatabad D, Sarkar R. Glutathione as a skin whitening agent: Facts, myths, evidence and controversies. Indian J Dermatol Venereol Leprol 2016;82:262-72.  Back to cited text no. 12
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13.
Antonioni MB, Fontana M, Salzmann LB, Inglehart MR. Pediatric dentists' silver diamine fluoride education, knowledge, attitudes, and professional behavior: A national survey. J Dent Educ 2019;83:173-82.  Back to cited text no. 13
    
14.
Zhao IS, Gao SS, Hiraishi N, Burrow MF, Duangthip D, Mei ML, et al. Mechanisms of silver diamine fluoride on arresting caries: A literature review. Int Dent J 2018;68:67-76.  Back to cited text no. 14
    
15.
Crystal YO, Marghalani AA, Ureles SD, Wright JT, Sulyanto R, Divaris K, et al. Use of silver diamine fluoride for dental caries management in children and adolescents, including those with special health care needs. Pediatr Dent 2017;39:135-45.  Back to cited text no. 15
    
16.
Knight GM, McIntyre JM, Mulyani. The effect of silver fluoride and potassium iodide on the bond strength of auto cure glass ionomer cement to dentine. Aust Dent J 2006;51:42-5.  Back to cited text no. 16
    
17.
Uchil SR, Suprabha BS, Suman E, Shenoy R, Natarajan S, Rao A. Effect of three silver diamine fluoride application protocols on the microtensile bond strength of resinmodified glassionomer cement to carious dentin in primary teeth. J Indian Soc Pedod Prev Dent 2020;38:138-44.  Back to cited text no. 17
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18.
Amato E, Diaz-Fernandez YA, Taglietti A, Pallavicini P, Pasotti L, Cucca L, et al. Synthesis, characterization and antibacterial activity against Gram positive and Gram negative bacteria of biomimetically coated silver nanoparticles. Langmuir 2011;27:9165-73.  Back to cited text no. 18
    
19.
Taglietti A, Diaz Fernandez YA, Amato E, Cucca L, Dacarro G, Grisoli P, et al. Antibacterial activity of glutathione-coated silver nanoparticles against Gram positive and Gram negative bacteria. Langmuir 2012;28:8140-8.  Back to cited text no. 19
    
20.
Manimaran VS, Srinivasulu S, Rajesh Ebenezar A, Mahalaxmi S, Srinivasan N. Application of a proanthocyanidin agent to improve the bond strength of root dentin treated with sodium hypochlorite. J Conserv Dent 2011;14:306-8.  Back to cited text no. 20
[PUBMED]  [Full text]  


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